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Krishna Moorthy PS, Sakijan AS, Permal D, Gaaffar IF, Kepli AS, Sahimi HI. Current review of acute type A aortic dissection in Malaysia. Indian J Thorac Cardiovasc Surg 2023; 39:297-307. [PMID: 38093916 PMCID: PMC10713945 DOI: 10.1007/s12055-023-01608-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 12/17/2023] Open
Abstract
Acute type A aortic dissection (ATAAD) still poses significant challenges and management dilemmas for cardiovascular surgeons worldwide. Despite the continuous improvement in diagnosis and management strategies for ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable especially those with malperfusion syndrome (MPS). This review is based on the current literature and includes the results from the Aortic Registry of National Heart Institute of Malaysia (NHIM) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is often delayed leading to variable outcomes. High index of suspicion and urgent treatment is required to tackle this dynamic disease which include the variation in presentation and clinical course. Different surgical techniques and perfusion strategies have been described to save patients. Complex techniques such as total arch replacement (TAR) with frozen elephant trunk and valve sparing root surgery may provide long-term benefit in selected patients, but require significant surgical expertise and experience.
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Affiliation(s)
- Paneer Selvam Krishna Moorthy
- Department of Cardiothoracic & Vascular Surgery, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Abdul Samad Sakijan
- Department of Imaging & Non-Invasive Laboratory, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Deventhiran Permal
- Department of Imaging & Non-Invasive Laboratory, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Intan Fariza Gaaffar
- Clinical Research Department, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Aini Syakirin Kepli
- Clinical Research Department, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Haidatul Insyirah Sahimi
- Clinical Research Department, National Heart Institute, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
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Schillaci M, Marchetti D, Andreini D. In search of new gatekeepers: coronary CT (Computed Tomography) in acute coronary syndrome. Eur Heart J Suppl 2023; 25:B1-B6. [PMID: 37091644 PMCID: PMC10120979 DOI: 10.1093/eurheartjsupp/suad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Coronary computed tomography (CCT) is a non-invasive imaging method that allows visualization of the epicardial coronary arteries. The diagnostic and prognostic role of CCT has been demonstrated by various randomized trials to such an extent that it has been included as a Class I, level of evidence B recommendation in the latest European Society of Cardiology (ESC) guidelines for the diagnosis of chronic coronary syndrome in patients at intermediate-low cardiovascular risk. In addition to the anatomical evaluation, the CCT allows to evaluate the presence of high-risk characteristics of the atherosclerotic plaque (napkin-ring sign, positive remodelling, spotty calcification, and low-attenuation plaque), thus discriminating the stability of the atheromatous pathology. Furthermore, among the potential of cardiac CT in the emergency department, the possibility of making a triple rule-out must be underlined, excluding three potential big killers as the cause of acute chest pain: acute coronary syndrome, pulmonary embolism, and aortic dissection. Various randomized clinical studies have demonstrated that the prognosis of the patient with chronic coronary artery disease (CAD) improves only if a haemodynamically significant stenosis is treated, generally investigated with invasive fractional flow reserve (FFR); CCT technological advances have made it possible to create an algorithm for calculating the FFR-CT, an index of haemodynamic significance of coronary stenosis, whose correlation with the invasive FFR data and, consequently, with the prognosis has been demonstrated of patients with CAD.
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Affiliation(s)
- Matteo Schillaci
- IRCCS Galeazzi Sant'Ambrogio Hospital, UOC University Cardiology, Milan
| | - Davide Marchetti
- IRCCS Galeazzi Sant'Ambrogio Hospital, UOC University Cardiology, Milan
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Fusaro M, Caruso D, Tessarin G, de Santis D, Balestriero G, Bortolanza C, Panvini N, Polidori T, Laghi A, Morana G. Comparison of Triple-Rule-Out Prospectively ECG-triggered Systolic and Diastolic Acquisition Protocol in Patients With Acute Chest Pain. J Thorac Imaging 2022; 37:W72-W77. [PMID: 34534998 DOI: 10.1097/rti.0000000000000620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to compare image quality and coronary interpretability of triple-rule-out systolic and diastolic protocols in patients with acute chest pain. MATERIALS AND METHODS From March 2016 to October 2017 the authors prospectively enrolled patients with undifferentiated acute chest pain, who were at low to intermediate cardiovascular risk. Those with heart rate >75 bpm underwent a systolic prospectively triggered acquisition (systolic triggering [ST]), and in those with ≤75 bpm, end-diastolic triggering (DT) was instead performed. Examinations were evaluated for coronary artery disease, aortic dissection, and pulmonary embolism. Image quality was assessed using a Likert scale. Coronary arteries interpretability was evaluated both on a per-vessel and a per segment basis. The occurrence of major adverse cardiovascular events was investigated. RESULTS The final study population was 189 patients. Fifty-two patients (27.5%) underwent systolic acquisition and 137 (72.5%) underwent diastolic acquisition. No significant differences in overall image quality were observed between DT and ST groups (median score 5 [interquartile ranges 4 to 5] vs. 4 [interquartile ranges 4 to 5], P =0.074). Although both DT and ST protocols showed low percentages of noninterpretable coronary arteries on a per-vessel (1.5% and 6.7%, respectively) and per-segment analysis (1% and 4.7%, respectively), these percentages resulted significantly higher for ST groups ( P <0.001). Obstructive coronary stenosis was observed in 18 patients. Only one case of pulmonary embolism was diagnosed and no cases of aortic dissection were found in our population. No death or major adverse cardiovascular events were observed during follow-up among the 2 groups. CONCLUSIONS Results showed that triple-rule-out computed tomography angiography is a reliable technique in patients with acute chest pain and that an ST acquisition protocol could be considered an alternative acquisition protocol in patients with higher heart rate, reaching a good image quality.
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Affiliation(s)
- Michele Fusaro
- Department of Radiology, Santa Maria di Ca' Foncello Hospital, Treviso
| | - Damiano Caruso
- Department of Radiological, Oncological and Pathological Science, Sant'Andrea Hospital, "La Sapienza" University of Rome, Rome
| | - Giovanni Tessarin
- Department of Medicine-DIMED, Institute of Radiology, University of Padova, Padua, Italy
| | - Domenico de Santis
- Department of Radiological, Oncological and Pathological Science, Sant'Andrea Hospital, "La Sapienza" University of Rome, Rome
| | | | - Carlo Bortolanza
- Department of Radiology, Santa Maria di Ca' Foncello Hospital, Treviso
| | - Nicola Panvini
- Department of Radiological, Oncological and Pathological Science, Sant'Andrea Hospital, "La Sapienza" University of Rome, Rome
| | - Tiziano Polidori
- Department of Radiological, Oncological and Pathological Science, Sant'Andrea Hospital, "La Sapienza" University of Rome, Rome
| | - Andrea Laghi
- Department of Radiological, Oncological and Pathological Science, Sant'Andrea Hospital, "La Sapienza" University of Rome, Rome
| | - Giovanni Morana
- Department of Radiology, Santa Maria di Ca' Foncello Hospital, Treviso
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Computational Fluid Dynamic Technique for Assessment of How Changing Character of Blood Flow and Different Value of Hct Influence Blood Hemodynamic in Dissected Aorta. Diagnostics (Basel) 2021; 11:diagnostics11101866. [PMID: 34679564 PMCID: PMC8534802 DOI: 10.3390/diagnostics11101866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 11/17/2022] Open
Abstract
Using computer tomography angiography (CTA) and computational structural analysis, we present a non-invasive method of mass flow rate/velocity and wall stress analysis in type B aortic dissection. Three-dimensional (3D) computer models of the aorta were calculated using pre-operative (baseline) and post-operative CT data from 12 male patients (aged from 51 to 64 years) who were treated for acute type B dissection. A computational fluid dynamics (CFD) technique was used to quantify the displacement forces acting on the aortic wall in the areas of endografts placement. The mass flow rate and wall stress were measured and quantified using the CFD technique. The CFD model indicated the places with a lower value of blood velocity and shear rate, which corelated with higher blood viscosity and a probability of thrombus appearance. Moreover, with the increase in Hct, blood viscosity also increased, while the intensity of blood flow provoked changing viscosity values in these areas. Furthermore, the velocity gradient near the tear surface caused high wall WSS; this could lead to a decreased resistance in the aorta’s wall with further implications to a patient.
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Martin SS, Mastrodicasa D, van Assen M, De Cecco CN, Bayer RR, Tesche C, Varga-Szemes A, Fischer AM, Jacobs BE, Sahbaee P, Griffith LP, Matuskowitz AJ, Vogl TJ, Schoepf UJ. Value of Machine Learning-based Coronary CT Fractional Flow Reserve Applied to Triple-Rule-Out CT Angiography in Acute Chest Pain. Radiol Cardiothorac Imaging 2020; 2:e190137. [PMID: 33778579 DOI: 10.1148/ryct.2020190137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/18/2020] [Accepted: 02/17/2020] [Indexed: 11/11/2022]
Abstract
Purpose To evaluate the additional value of noninvasive artificial intelligence (AI)-based CT-derived fractional flow reserve (CT FFR), derived from triple-rule-out coronary CT angiography for acute chest pain (ACP) in the emergency department (ED) setting. Materials and Methods AI-based CT FFR from triple-rule-out CT angiography data sets was retrospectively obtained in 159 of 271 eligible patients (102 men; mean age, 57.0 years ± 9.7 [standard deviation]) presenting to the ED with ACP. The agreement between CT FFR (≤ 0.80) and stenosis at triple-rule-out CT angiography (≥ 50%), as well as downstream cardiac diagnostic testing, was investigated. Furthermore, the predictive value of CT FFR for coronary revascularization and major adverse cardiac events (MACE) was assessed over a 1-year follow-up period. Results CT FFR and triple-rule-out CT angiography demonstrated agreement in severity of coronary artery disease (CAD) in 52% (82 of 159) of all cases. CT FFR of 0.80 and less served as a better predictor for coronary revascularization and MACE than stenosis of 50% and greater at triple-rule-out CT angiography (odds ratio, 3.4; 95% confidence interval: 1.4, 8.2 vs odds ratio, 2.2; 95% confidence interval: 0.9, 5.3) (P < .01). In the subgroup of patients with additional noninvasive cardiac testing (94 of 159), there was higher agreement as to the presence or absence of significant disease with CT FFR (55%) than with coronary triple-rule-out CT angiography (47%) (P = .23). Conclusion CT FFR derived from triple-rule-out CT angiography was a better predictor for coronary revascularization and MACE and showed better agreement with additional diagnostic testing than triple-rule-out CT angiography. Therefore, CT FFR may improve the specificity in identifying patients with ACP with significant CAD in the ED setting and reduce unnecessary downstream testing.© RSNA, 2020See also the commentary by Ihdayhid and Ben Zekry in this issue.
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Affiliation(s)
- Simon S Martin
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Domenico Mastrodicasa
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Marly van Assen
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Carlo N De Cecco
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Richard R Bayer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Andreas M Fischer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Brian E Jacobs
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Pooyan Sahbaee
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - L Parkwood Griffith
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Andrew J Matuskowitz
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - Thomas J Vogl
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr, Charleston, SC 29425-2260 (S.S.M., D.M., M.v.A., C.N.D.C., R.R.B., C.T., A.V.S., A.M.F., B.E.J., L.P.G., U.J.S.); Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany (S.S.M., T.J.V.); Stanford University School of Medicine, Department of Radiology, Stanford, Calif (D.M.); Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (C.N.D.C.); Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.R.B.); Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany (C.T.); Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany (C.T.); Siemens Medical Solutions USA, Malvern, Pa (P.S.); and Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC (A.J.M.)
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In-Hospital Cost Comparison of Triple-Rule-Out Computed Tomography Angiography Versus Standard of Care in Patients With Acute Chest Pain. J Thorac Imaging 2020; 35:198-203. [PMID: 32032251 DOI: 10.1097/rti.0000000000000474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the utilization of invasive and noninvasive tests and compare cost in patients presenting with chest pain to the emergency department (ED) who underwent either triple-rule-out computed tomography angiography (TRO-CTA) or standard of care. MATERIALS AND METHODS We performed a retrospective single-center analysis of 2156 ED patients who presented with acute chest pain with a negative initial troponin and electrocardiogram for myocardial injury. Patient cohorts matched by patient characteristics who had undergone TRO-CTA as a primary imaging test (n=1139) or standard of care without initial CTA imaging (n=1017) were included in the study. ED visits, utilization of tests, and costs during the initial episode of hospital care were compared. RESULTS No significant differences in the diagnosis of coronary artery disease, pulmonary embolism, or aortic dissection were observed. Median ED waiting time (4.5 vs. 7.0 h, P<0.001), median total length of hospital stay (5.0 vs. 32.0 h, P<0.001), hospital admission rate (12.6% vs. 54.2%, P<0.001), and ED return rate to our hospital within 30 days (3.5% vs. 14.6%, P<0.001) were significantly lower in the TRO-CTA group. Moreover, reduced rates of additional testing and invasive coronary angiography (4.9% vs. 22.7%, P<0.001), and ultimately lower total cost per patient (11,783$ vs. 19,073$, P<0.001) were observed in the TRO-CTA group. CONCLUSIONS TRO-CTA as an initial imaging test in ED patients presenting with acute chest pain was associated with shorter ED and hospital length of stay, fewer return visits within 30 days, and ultimately lower ED and hospitalization costs.
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Monica MP, Merkely B, Szilveszter B, Drobni ZD, Maurovich-Horvat P. Computed Tomographic Angiography for Risk Stratification in Patients with Acute Chest Pain - The Triple Rule-out Concept in the Emergency Department. Curr Med Imaging 2020; 16:98-110. [PMID: 32003310 DOI: 10.2174/1573405614666180604095120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 06/20/2017] [Accepted: 03/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Acute chest pain is one of the most common reasons for Emergency Department (ED) visits and hospital admissions. As this could represent the first symptom of a lifethreatening condition, urgent identification of the etiology of chest pain is of utmost importance in emergency settings. Such high-risk conditions that can present with acute chest pain in the ED include Acute Coronary Syndromes (ACS), Pulmonary Embolisms (PE) and Acute Aortic Syndromes (AAS). DISCUSSION The concept of Triple Rule-out Computed Tomographic Angiography (TRO-CTA) for patients presenting with acute chest pain in the ED is based on the use of coronary computed tomographic angiography as a single imaging technique, able to diagnose or exclude three lifethreatening conditions in one single step: ACS, AAS and PE. TRO-CTA protocols have been proved to be efficient in the ED for diagnosis or exclusion of life-threatening conditions and for differentiation between various etiologies of chest pain, and application of the TRO-CTA protocol in the ED for acute chest pain of uncertain etiology has been shown to improve the further clinical evaluation and outcomes of these patients. CONCLUSION This review aims to summarize the main indications and techniques used in TRO protocols in EDs, and the role of TRO-CTA protocols in risk stratification of patients with acute chest pain.
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Affiliation(s)
- Marton-Popovici Monica
- Department of Internal Medicine and Critical Care, Swedish Medical Center, Edmonds, Washington, United States
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsófia Dora Drobni
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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A Secondary Analysis to Identify Patient-Centered Outcomes in the ACR’s Appropriateness Criteria. J Am Coll Radiol 2019; 16:1645-1655. [DOI: 10.1016/j.jacr.2019.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 11/20/2022]
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9
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Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J 2019; 39:739-749d. [PMID: 29106452 DOI: 10.1093/eurheartj/ehx319] [Citation(s) in RCA: 201] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/13/2017] [Indexed: 01/16/2023] Open
Abstract
Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
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Affiliation(s)
| | - Troy M LaBounty
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
| | - Kim A Eagle
- University of Michigan Cardiovascular Center, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105, USA
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Gudbjartsson T, Ahlsson A, Geirsson A, Gunn J, Hjortdal V, Jeppsson A, Mennander A, Zindovic I, Olsson C. Acute type A aortic dissection - a review. SCAND CARDIOVASC J 2019; 54:1-13. [PMID: 31542960 DOI: 10.1080/14017431.2019.1660401] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate.
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Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anders Ahlsson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jarmo Gunn
- Department of Cardiothoracic Surgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ari Mennander
- Tampere University Heart Hospital and Tampere University, Tampere, Finland
| | - Igor Zindovic
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Department of Cardiothoracic Surgery, Lund, Sweden
| | - Christian Olsson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Morsbach F, Hinzpeter R, Higashigaito K, Benz D, Manka R, Keller DI, Alkadhi H. Chest pain CT in the Emergency Department: evaluating the coronary arteries even when not specifically asked for? Acta Radiol 2018; 59:1309-1315. [PMID: 29486599 DOI: 10.1177/0284185118758121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Computed tomography (CT) for excluding acute aortic syndrome (AAS) and pulmonary embolism (PE) simultaneously in patients with chest pain could be used to exclude coronary artery disease (CAD). Purpose To evaluate the frequency of further testing for CAD in patients receiving a CT in the emergency department (ED) for simultaneous evaluation for AAS and PE. Material and Methods This retrospective study was conducted over a three-year period including all patients with acute chest pain visiting our ED. All patients were included that received an electrocardiography (ECG)-gated CT of the entire chest enquiring simultaneously for AAS and PE. Those patients were followed up for 30 days after their initial ED visit whether they received further testing for CAD. Results Within the study period, a total of 157 patients with acute chest pain received a chest pain CT for simultaneous evaluation of both AAS and PE. Image quality was deemed sufficient to evaluate the coronary arteries in 80% of the patients. Thirty-seven patients (24%) underwent additional testing for CAD within 30 days of their ED visit, including catheter coronary angiography (n = 25), cardiac-stress single-photon emission-CT (n = 6), and cardiac magnetic resonance imaging (MRI) (n = 6). Conclusion Of patients presenting to the ED with acute chest pain who received a chest pain CT for simultaneous evaluation of AAS and PE, 24% had further imaging for CAD within 30 days of the initial ED visit. Immediate evaluation of the coronary arteries as part of a chest pain CT should be considered here for not delaying diagnosis.
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Affiliation(s)
- Fabian Morsbach
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Ricarda Hinzpeter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Kai Higashigaito
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - David Benz
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Robert Manka
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiology, University Heart Center Zurich, University of Zurich, Zurich, Switzerland
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Dagmar I Keller
- Institute for Emergency Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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Bhave NM, Nienaber CA, Clough RE, Eagle KA. Multimodality Imaging of Thoracic Aortic Diseases in Adults. JACC Cardiovasc Imaging 2018; 11:902-919. [DOI: 10.1016/j.jcmg.2018.03.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/28/2022]
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Chinnaiyan KM, Raff GL. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:62. [DOI: 10.1007/s11936-016-0484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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15
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Triple rule-out computed tomography for risk stratification of patients with acute chest pain. J Cardiovasc Comput Tomogr 2016; 10:291-300. [PMID: 27375202 DOI: 10.1016/j.jcct.2016.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 06/07/2016] [Indexed: 12/22/2022]
Abstract
AIMS Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain. METHODS We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings. RESULTS TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons). CONCLUSION Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores.
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Abstract
OBJECTIVE The objective of the present study is to quantify the diagnostic yield of triple-rule-out (TRO) CT for the evaluation of acute chest pain in emergency department patients. MATERIALS AND METHODS All TRO CT studies performed at our institution from 2006 to 2015 were reviewed. Scans were performed on a 256-MDCT scanner, with the use of ECG gating and a biphasic contrast injection. Radiology reports were reviewed to identify diagnoses that could explain chest pain, including coronary and noncoronary diagnoses, and significant incidental findings that did not account for the patient's presentation. The total numbers of coronary and noncoronary diagnoses and incidental findings were calculated. RESULTS Four of 1196 total cases that were identified were excluded from the study because of inadequate image quality. A total of 970 patients (81.4%) had a negative study result without a significant coronary or noncoronary diagnosis. A total of 139 patients (11.7%) had significant coronary artery disease (50% stenosis or greater). One hundred six patients (8.9%) had a noncoronary diagnosis that could explain chest pain (p < 0.02), most commonly pulmonary embolism (28 patients [2.3%]), aortic aneurysm (24 patients [2.0%]), or pneumonia (20 patients [1.7%]). Thirty cases (27.3%) of pulmonary embolism and aortic pathologic findings would not have been detected with coronary CT angiography because of unopacified right-side circulation or limited z-axis coverage. A total of 528 incidental findings not considered to explain chest pain were noted in 418 patients (35.1%). CONCLUSION In 8.9% of patients, TRO CT detected a significant noncoronary diagnosis that could explain acute chest pain, including pathologic findings that would not be identified on dedicated coronary CT angiography.
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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ACR Appropriateness Criteria Acute Nonspecific Chest Pain—Low Probability of Coronary Artery Disease. J Am Coll Radiol 2015; 12:1266-71. [DOI: 10.1016/j.jacr.2015.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/24/2022]
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Sawyer KN, Shah P, Qu L, Kurz MC, Clark CL, Swor RA. Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department. West J Emerg Med 2015; 16:677-82. [PMID: 26587090 PMCID: PMC4644034 DOI: 10.5811/westjem.2015.6.25958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/01/2015] [Accepted: 06/30/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. Methods This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. Results A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6mSv). No patient in either group had a related 30-day revisit. Conclusion Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.
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Affiliation(s)
- Kelly N Sawyer
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Payal Shah
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Lihua Qu
- William Beaumont Hospital, Research Institute Center for Outcomes Research, Royal Oak, Michigan
| | - Michael C Kurz
- University of Alabama School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Carol L Clark
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Robert A Swor
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
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Burris AC, Boura JA, Raff GL, Chinnaiyan KM. Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain. JACC Cardiovasc Imaging 2015; 8:817-25. [DOI: 10.1016/j.jcmg.2015.02.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/10/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023]
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Qahtani SA, Kandeel AY, Breault S, Jouannic AM, Qanadli SD. Prevalence of Acute Coronary Syndrome in Patients Suspected for Pulmonary Embolism or Acute Aortic Syndrome: Rationale for the Triple Rule-Out Concept. J Clin Med Res 2015; 7:627-31. [PMID: 26124909 PMCID: PMC4471750 DOI: 10.14740/jocmr2197w] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aims of the study were to evaluate the prevalence of acute coronary syndrome (ACS) among patients presenting with atypical chest pain who are evaluated for acute aortic syndrome (AAS) or pulmonary embolism (PE) with computed tomoangiography (CTA) and discuss the rationale for the use of triple rule-out (TRO) protocol for triaging these patients. METHODS This study is a retrospective analysis of patients presenting with atypical chest pain and evaluated with thoracic (CTA), for suspicion of AAS/PE. Two physicians reviewed patient files for demographic characteristics, initial CT and final clinical diagnosis. Patients were classified according to CTA finding into AAS, PE and other diagnoses and according to final clinical diagnosis into AAS, PE, ACS and other diagnoses. RESULTS Four hundred and sixty-seven patients were evaluated: 396 (84.8%) patients for clinical suspicion of PE and 71 (15.2%) patients for suspicion of AAS. The prevalence of ACS and AAS was low among the PE patients: 5.5% and 0.5% respectively (P = 0.0001), while the prevalence of ACS and PE was 18.3% and 5.6% among AAS patients (P = 0.14 and P = 0.34 respectively). CONCLUSION The prevalence of ACS and AAS among patients suspected clinically of having PE is limited while the prevalence of ACS and PE among patients suspected clinically of having AAS is significant. Accordingly patients suspected for PE could be evaluated with dedicated PE CTA while those suspected for AAS should still be triaged using TRO protocol.
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Affiliation(s)
- Saad Al Qahtani
- Department of Radiology & Medical Imaging, Armed Forces Hospital, Southern Region, Saudi Arabia
| | - Ahmed Y Kandeel
- Department of Radiology & Medical Imaging, Armed Forces Hospital, Southern Region, Saudi Arabia
| | - Stephane Breault
- Cardio-Thoracic and Vascular Unit, Department of Radiology, University Hospital of Lausanne, Switzerland
| | - Anne-Marie Jouannic
- Cardio-Thoracic and Vascular Unit, Department of Radiology, University Hospital of Lausanne, Switzerland ; Quantitative Medical Imaging Laboratory, Department of Radiology, University Hospital of Lausanne, Switzerland
| | - Salah D Qanadli
- Cardio-Thoracic and Vascular Unit, Department of Radiology, University Hospital of Lausanne, Switzerland ; Quantitative Medical Imaging Laboratory, Department of Radiology, University Hospital of Lausanne, Switzerland
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Abstract
A new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies (including biomarkers and imaging), endograft design, and surgical treatment, which have led to a better understanding of the epidemiology, risk factors, and molecular nature of aortic dissection. Although open surgery is the main treatment for proximal aortic repair, use of endovascular management is now established for complicated distal dissection and distal arch repair, and has recently been discussed as a pre-emptive measure to avoid late complications by inducing aortic remodelling.
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Affiliation(s)
| | - Rachel E Clough
- King's College London, Cardiovascular Imaging Department, Lambeth Wing St Thomas, London, UK
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Pursnani A, Chou ET, Zakroysky P, Deaño RC, Mamuya WS, Woodard PK, Nagurney JT, Fleg JL, Lee H, Schoenfeld D, Udelson JE, Hoffmann U, Truong QA. Use of coronary artery calcium scanning beyond coronary computed tomographic angiography in the emergency department evaluation for acute chest pain: the ROMICAT II trial. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.114.002225. [PMID: 25710925 DOI: 10.1161/circimaging.114.002225] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether a coronary artery calcium (CAC) scan provides added value to coronary computed tomographic angiography (CCTA) in emergency department patients with acute chest pain remains unsettled. We sought to determine the value of CAC scan in patients with acute chest pain undergoing CCTA. METHODS AND RESULTS In the multicenter Rule Out Myocardial Infarction using Computer-Assisted Tomography (ROMICAT) II trial, we enrolled low-intermediate risk emergency department patients with symptoms suggesting acute coronary syndrome (ACS). In this prespecified subanalysis of 473 patients (54±8 years, 53% men) who underwent both CAC scanning and CCTA, the ACS rate was 8%. Overall, 53% of patients had CAC=0 of whom 2 (0.8%) developed ACS, whereas 7% had CAC>400 with 49% whom developed ACS. C-statistic of CAC>0 was 0.76, whereas that using the optimal cut point of CAC≥22 was 0.81. Continuous CAC score had lower discriminatory capacity than CCTA (c-statistic, 0.86 versus 0.92; P=0.03). Compared with CCTA alone, there was no benefit combining CAC score with CCTA (c-statistic, 0.93; P=0.88) or with selective CCTA strategies after initial CAC>0 or optimal cut point CAC≥22 (P≥0.09). Mean radiation dose from CAC acquisition was 1.4±0.7 mSv. Higher CAC scores resulted in more nondiagnostic CCTA studies although the majority remained interpretable. CONCLUSIONS In emergency department patients with acute chest pain, CAC score does not provide incremental value beyond CCTA for ACS diagnosis. CAC=0 does not exclude ACS, nor a high CAC score preclude interpretation of CCTA in most patients. Thus, CAC results should not influence the decision to proceed with CCTA, and the decision to perform a CAC scan should be balanced with the additional radiation exposure required. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01084239.
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Affiliation(s)
- Amit Pursnani
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Eric T Chou
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Pearl Zakroysky
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Roderick C Deaño
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Wilfred S Mamuya
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Pamela K Woodard
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - John T Nagurney
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Jerome L Fleg
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Hang Lee
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - David Schoenfeld
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - James E Udelson
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Udo Hoffmann
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.)
| | - Quynh A Truong
- From the Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology (A.P., W.S.M., U.H.), Emergency Department (J.T.N.), and Biostatistics Center (P.Z., H.L., D.S.), Massachusetts General Hospital, Harvard Medical School, Boston; Cardiology Division, Kaiser Permanente Fontana Medical Center, CA (E.T.C.); Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, New York (R.C.D., Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO (P.K.W.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.); and Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, MA (J.E.U.).
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Kochav J, Simprini L, Weinsaft JW. Imaging of the right heart--CT and CMR. Echocardiography 2014; 32 Suppl 1:S53-68. [PMID: 25244072 DOI: 10.1111/echo.12212] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Right ventricular (RV) structure and function is of substantial importance in a broad variety of clinical conditions. Cardiac magnetic resonance (CMR) and computed tomography (CT) each provide three-dimensional RV imaging, high-resolution evaluation of RV structure/anatomy, and accurate functional assessment without geometric assumptions. This is of particular significance for the RV, where complex geometry compromises reliance on indices derived from two-dimensional (2D) imaging planes. CMR flow-based imaging can be applied to right-sided heart valves, enabling evaluation of hemodynamic and valvular dysfunction that may contribute to or result from RV dysfunction. Tissue characterization imaging by both CMR and CT provides valuable complementary assessment of the RV. Changes in myocardial tissue composition provide a mechanistic substrate for RV dysfunction and cardiac arrhythmias. This review provides an overview of RV imaging by both CMR and CT, with focus on assessment of RV structure/function, flow, and tissue characterization. Emerging evidence and established guidelines are discussed in the context of imaging contributions to diagnosis, prognostic risk stratification and disease management of clinical conditions that impact the right ventricle.
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Affiliation(s)
- Jonathan Kochav
- Duke University School of Medicine, Durham, North Carolina; Weill Cornell Medical College, New York, New York
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Raff GL, Chinnaiyan KM, Cury RC, Garcia MT, Hecht HS, Hollander JE, O'Neil B, Taylor AJ, Hoffmann U. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 2014; 8:254-71. [DOI: 10.1016/j.jcct.2014.06.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 02/06/2023]
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Keenan NG, Pugliese F, Davies LC. The role of computed tomography in cardiovascular imaging: from X-ray department to emergency room. Expert Rev Cardiovasc Ther 2014; 12:57-69. [DOI: 10.1586/14779072.2014.870034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ayaram D, Bellolio MF, Murad MH, Laack TA, Sadosty AT, Erwin PJ, Hollander JE, Montori VM, Stiell IG, Hess EP. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med 2013; 20:861-71. [PMID: 24050793 DOI: 10.1111/acem.12210] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/14/2013] [Accepted: 03/17/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of "triple rule-out" (TRO) computed tomography (CT) to other diagnostic modalities commonly used to evaluate patients with nontraumatic chest pain (dedicated coronary, pulmonary embolism [PE], and aortic dissection CT; invasive coronary angiography; and nuclear stress testing). METHODS Four electronic databases were searched, along with reference lists and contacted content experts, for relevant studies from inception until October 2012. Eligible studies enrolled patients with nontraumatic chest pain, shortness of breath, suspected acute coronary syndrome (ACS), PE, or aortic dissection; used at least 64-slice CT technology; and compared TRO CT to another diagnostic modality. RESULTS Eleven studies enrolling 3,539 patients (791 TRO and 2,748 non-TRO) were included (one randomized controlled trial and 10 observational). There was no significant difference in image quality between TRO and dedicated CT scans. TRO CT had the following pooled diagnostic accuracy estimates for coronary artery disease: sensitivity of 94.3% (95% confidence interval [CI] = 89.1% to 97.5%), specificity of 97.4% (95% CI = 96.1% to 98.4%), positive likelihood ratio (LR+) of 17.71 (95% CI = 3.92 to 79.96), and negative likelihood ratio (LR-) of 0.08 (95% CI = 0.02 to 0.27). There were insufficient numbers of patients with PE or aortic dissection to generate diagnostic accuracy estimates for these conditions. Use of TRO CT involved greater radiation exposure (mean difference [MD] = 4.84 mSv, 95% CI = 1.65 to 8.04 mSv) and contrast exposure (MD = 38.0 mL, 95% CI = 28.1 to 48.0 mL) compared to non-TRO CT patients. CONCLUSIONS Triple rule-out CT is highly accurate for detecting coronary artery disease. Given the low (<1%) prevalence of PE and aortic dissection in the included studies, and the increased radiation and contrast exposure, there are insufficient data to recommend use of TRO CT in the diagnosis of these conditions.
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Affiliation(s)
- David Ayaram
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - M. Fernanda Bellolio
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - M. Hassan Murad
- The Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
- The Department of Internal Medicine; Division of Preventive Medicine; Mayo Clinic; Rochester MN
| | - Torrey A. Laack
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - Annie T. Sadosty
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - Patricia J. Erwin
- The Mayo Medical Libraries; Mayo Clinic College of Medicine; Rochester MN
| | - Judd E. Hollander
- The Department of Emergency Medicine; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Victor M. Montori
- The Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
- The Department of Internal Medicine; Division of Endocrinology and Metabolism; Mayo Clinic; Rochester MN
| | - Ian G. Stiell
- The Department of Emergency Medicine and Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Erik P. Hess
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
- The Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
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Abstract
The term acute aortic syndrome (AAS) incorporates aortic dissection, intramural haematoma, and penetrating atherosclerotic ulcer. The common feature of these entities is disruption of the medial layer of the aortic wall. Owing to the life-threatening nature of these conditions, prompt and accurate diagnosis is of paramount importance--misdiagnosis can be fatal. The noninvasive imaging techniques that have a fundamental role in the diagnosis and management of patients with AAS include CT, MRI, transoesophageal echocardiography (TEE), and transthoracic echocardiography (TTE). CT is the most-commonly used imaging modality owing to its wide availability, accuracy, and large field of view. CT plus TTE is the best combination for diagnosing AAS and its complications, and allows important morphological and dynamic aspects of AAS to be assessed and appropriately managed. Ideally, TEE should be performed immediately before surgery or endovascular treatment, in the operating theatre and under general anaesthesia. In stable patients with an uncertain diagnosis of intramural haematoma despite high clinical suspicion, MRI is the technique of choice to make a definitive diagnosis. Imaging techniques have an important role in the primary diagnosis, treatment strategy, and risk stratification of patients with AAS.
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Evangelista A, Carro A, Moral S, Teixido-Tura G, Rodríguez-Palomares JF, Cuéllar H, García-Dorado D. Imaging modalities for the early diagnosis of acute aortic syndrome. Nat Rev Cardiol 2013; 10:477-86. [DOI: 10.1038/nrcardio.2013.92] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bilolikar AN, Chinnaiyan KM. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Is it prime time for "rapid comprehensive cardiopulmonary imaging" in the emergency department? Cardiol Clin 2012; 30:523-32. [PMID: 23102029 DOI: 10.1016/j.ccl.2012.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Reducing hospital admissions through improved risk stratification of patients with potential acute coronary syndrome represents a critical focus for reducing health care expenditure. Coronary computed tomographic angiography (CTA) has been used with increasing frequency as part of the evaluation of chest pain in the Emergency Department. In the appropriate group of patients at low to intermediate risk CTA appears to be an excellent evaluation strategy, safely and efficiently allowing for the rapid discharge of patients home.
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Foster TA, Shapiro MD. The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done, and If So, How? CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9152-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Current triage strategies are not effective in correctly identifying patients suffering from acute coronary syndrome (ACS). The diagnostic workup of patients presenting with acute chest pain continues to represent a major challenge for emergency department (ED) personnel. This statement holds especially true for patients with a low to intermediate likelihood for ACS. Taking current concepts for the diagnosis and management of patients presenting with acute chest pain to the ED into account, this article discusses the evidence and potential role of coronary computed tomography angiography to improve management of patients with possible ACS.
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